NSTEMI treatment: should we always follow the guidelines?

Non-ST elevation myocardial infarction (NSTEMI) has been diagnosed more often in recent years, not only since the introduction of high-sensitive troponin assays, but also because of the ageing population. The outcome is rather good in the short term; however, in the long term the outcome is poor due to the high incidence of co-morbidities such as renal failure, diabetes and hypertension. The diagnosis of NSTEMI is rather difficult. During the 2018 ESC meeting an update of the universal definition of MI was presented [1]. A diagnosis of NSTEMI can only be made if acute myocardial injury (defined as a rise and/or fall of cardiac troponin (cTn) above the 99th percentile upper reference limit (URL)) is present in combination with acute myocardial ischaemia. Type 1 MI is caused by atherosclerosis (plaque rupture or erosion), whereas type 2 MI is the result of an imbalance between oxygen demand and supply (hypertension, anaemia or tachycardia) (Fig. 1). Only patients with type I MI might benefit from early angiography and/or revascularisation; however, in daily practice it is not easy to discriminate between type 1 and type 2 MI